Century Surety Insurance

RESIDENTIAL CARE / GROUP HOME QUESTIONNAIRE

Complete a questionnaire for each location and submit with the completed CGL application

Applicant’s Name______Policy #

DBA______

Business Location

Contact for InspectionTelephone #

MailingAddress______

______

LICENSE AND OPERATIONS

License # and provider type Copy attached? [Yes] [No]

If none, or not attached, why?

Has license ever been suspended/revoked?If yes, explain ______

Is the facility related by ownership or administration to any hospital? If so, explain

Below, enter the number and type of staff per shift.

RN / LPN / Other Employees / Volunteers
1st Shift
2nd Shift
3rd Shift

Describe handling of medical emergencies (M.D. on call, transfer arrangement with hospital, etc.)

Describe procedure for disposing of infectious waste.

Provide details of occupancy and emergency evacuation plan, by floor. ______

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BUILDING AND EQUIPMENT

Age and type of heating system

Age of wiring system Circuit Breakers, fuses, or other

Number and placement of smoke detectors

Fire Alarm Central Station Local Sprinkler system extent

Swimming pool Spas Bath/Shower with non-skid surfaces

RESIDENTS AND ACTIVITIES

Total number of residents Number of residents using wheelchairs

Number of residents using walkers Number of residents confined to bed

Number of residents under 18 , adult (under 65) , adult (over 65)

Complete the following with the number of residents in each category.

Mentally ill / disabled / Alzheimer
Developmentally disabled / AIDS
Other emotionally disturbed / Hospice or Respite
Court appointed / Day care (only)

Are any care services provided off premises? If so, describe. ______

What degree of care do the majority of residents require? ______

What degree of care does the most dependent of residents require?(Refer to eating, walking, dressing, bathing, stairs, or other care)______

______

Describe the facility’s policy on restraints. ______

Describe procedures in place to identify and control the following:

  • New and existing residents as “wanderers”
  • New and existing residents with (or developing) serious health problems

Do residents participate in cooking, cleaning, other household chores or activities requiring the use of tools or equipment? If so, describe. ______

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Does the facility use any sub or independent contractors?. If so, are certificates of insurance required and kept on file?

Additional information or comments: ______

THE APPLICATION AND THIS QUESTIONNAIRE WILL BECOME A PART OF ANY POLICY ISSUED TO YOU. BY ACCEPTING THIS POLICY, YOU AGREE THAT THE STATEMENTS ON YOUR APPLICATION AND THIS QUESTIONNAIRE ARE TRUE AND CORRECT. THIS POLICY IS ISSUED RELYING ON THE ACCURACY OF THESE STATEMENTS.

Applicant’s SignatureProducer’s SignatureDate

This questionnaire does not bind any of the parties to complete the insurance transaction. Routine inquiries may be made to verify applicable information.

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